Healthcare Provider Details

I. General information

NPI: 1205640877
Provider Name (Legal Business Name): LYDIAH MBWIRIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

16100 BLUEGRASS CT
BELTON MO
64012-3339
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax: 816-922-4838
Mailing address:
  • Phone: 301-704-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2010013986
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: